Aromatherapy Client Intake Form

An intake form that collects a client's medical history, allergies, and preferences to flag potential contraindications before starting an aromatherapy treatment.

Use this template

Full Name

Nombre

Apellido

Gender

Male Female Other

Date of Birth

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Employment

Company Name

Civil Status

Single Married Divorced Widowed

Height (cm)

Weight (kg)

Select an appointment

Date

Time

Reason for visit

What are the oils or scents that you prefer?

What are the oils or scents that you do not prefer?

What are your expected results from this therapy?

Do you have any medical condition or illness that you would like us to know about?

Yes No

What is this medical condition that you want to share?

What symptoms have you experienced related to this condition/illness?

What treatments have you tried to cure this condition/illness?

Are you currently under any physical therapy or chiropractic treatment program?

Yes No

Do you have any physical injuries due to sports, accidents, or other causes?

Yes No

Are you pregnant or breastfeeding?

Yes No

Do you have allergies?

Yes No

Please list your allergies and what causes them

Are you currently taking any medication?

Yes No

Please list your medications and their purpose

Do you have hypertension?

Yes No

Do you have sensitive skin?

Yes No

Have you had any episode of epilepsy?

Yes No

Have you undergone any surgical operation?

Yes No

When did you have the procedure and what was the reason?

Patient Signature

Sign here

Date Signed

	Column 1	Column 2	Column 3
Row 1
Row 2

Aromatherapy Client Intake Form

Related templates